Skip to main content

Advertisement

SpringerLink
Log in

Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.

Aims

To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.

Methods

We queried the United Network for Organ Sharing for patients between ages 18–64 years undergoing liver transplantation in 2002–2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival.

Results

Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure.

Conclusion

Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

LT:

Liver transplantation

ESLD:

End-stage liver disease

MELD:

Model for end-stage liver disease

ACA:

Patient Protection and Affordable Care Act

US:

United States of America

UNOS:

United Network for Organ Sharing

ANOVA:

Analysis of variance

TIPSS:

Transjugular intrahepatic portosystemic shunt

DRI:

Donor risk index

LOS:

Length of stay

HR:

Hazard ratios

CI:

Confidence interval

ACS:

American College of Surgeons

References

  1. Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59:1144–1165. https://doi.org/10.1002/hep.26972.

    Article  PubMed  Google Scholar 

  2. UNOS. Transplant trends | UNOS. https://www.unos.org/data/transplant-trends/, 2017. Accessed 21 Feb 2018.

  3. Barritt AS, Telloni SA, Potter CW, Gerber DA, Hayashi PH. Local access to subspecialty care influences the chance of receiving a liver transplant. Liver Transplant. 2013;19:377–382. https://doi.org/10.1002/lt.23588.

    Article  Google Scholar 

  4. Adler JT, Dong N, Markmann JF, Schoenfeld D, Yeh H. Role of patient factors and practice patterns in determining access to liver waitlist. Am J Transplant. 2015;15:1836–1842. https://doi.org/10.1111/ajt.13301.

    Article  PubMed  CAS  Google Scholar 

  5. Flattau A, Olaywi M, Gaglio PJ, et al. Social barriers to listing for adult liver transplantation: their prevalence and association with program characteristics. Liver Transplant. 2011;17:1167–1175. https://doi.org/10.1002/lt.22357.

    Article  Google Scholar 

  6. Parikh ND, Hutton D, Marrero W, Sanghani K, Xu Y, Lavieri M. Projections in donor organs available for liver transplantation in the United States: 2014–2025. Liver Transplant. 2015;21:855–863. https://doi.org/10.1002/lt.24136.

    Article  Google Scholar 

  7. National Coverage Determination (NCD) for Adult Liver Transplantation (260.1). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=259&NcaName=Liver+Transplantation+for+Malignancies&ExpandComments=n&CommentPeriod=0&NCDId=70&ncdver=3&id=186&bc=gABAAAAAEEAAAA%3d%3d&, 2017. Accessed 24 July 2017.

  8. Yoo HY, Thuluvath PJ. Outcome of liver transplantation in adult recipients: influence of neighborhood income, education, and insurance. Liver Transplant. 2004;10:235–243. https://doi.org/10.1002/lt.20069.

    Article  Google Scholar 

  9. DuBay DA, MacLennan PA, Reed RD, et al. Insurance type and solid organ transplantation outcomes: a historical perspective on how medicaid expansion might impact transplantation outcomes. J Am Coll Surg. 2016;223:611–620.e614. https://doi.org/10.1016/j.jamcollsurg.2016.07.004.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Glueckert LN, Redden D, Thompson MA, et al. What liver transplant outcomes can be expected in the uninsured who become insured via the Affordable Care Act? Am J Transplant. 2013;13:1533–1540. https://doi.org/10.1111/ajt.12244.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  11. Kemmer N, Zacharias V, Kaiser TE, Neff GW. Access to liver transplantation in the MELD era: role of ethnicity and insurance. Dig Dis Sci. 2008;54:1794. https://doi.org/10.1007/s10620-008-0567-5.

    Article  PubMed  Google Scholar 

  12. Bryce CL, Angus DC, Arnold RM, et al. Sociodemographic differences in early access to liver transplantation services. Am J Transplant Off J Am Soc Transplant Am Soc of Transpl Surg. 2009;9:2092–2101. https://doi.org/10.1111/j.1600-6143.2009.02737.x.

    Article  CAS  Google Scholar 

  13. Bryce CL, Chang CC, Angus DC, Arnold RM, Farrell M, Roberts MS. The effect of race, sex, and insurance status on time-to-listing decisions for liver transplantation. J Transplant. 2010;2010:467976. https://doi.org/10.1155/2010/467976.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mejia A, Halff GA, Esterl R, et al. Outcome of liver transplantation in hispanics versus non-hispanics: is there a difference? Transplant Proc. 2002;34:1236–1238. https://doi.org/10.1016/S0041-1345(02)02799-9.

    Article  PubMed  CAS  Google Scholar 

  15. Tumin D, Beal EW, Mumtaz K, et al. Medicaid participation among liver transplant candidates after the Affordable Care Act medicaid expansion. J Am Coll Surg. 2017;225:173–180.e172. https://doi.org/10.1016/j.jamcollsurg.2017.05.004.

    Article  PubMed  Google Scholar 

  16. Tumin D, Hayes D, Washburn WK, Tobias JD, Black SM. Medicaid enrollment after liver transplantation: effects of medicaid expansion. Liver Transplant. 2016;22:1075–1084. https://doi.org/10.1002/lt.24480.

    Article  Google Scholar 

  17. Rongey C, Bambha K, Vanness D, et al. Employment and health insurance in long-term liver transplant recipients. Am J Transplant. 2005;5:1901–1908. https://doi.org/10.1111/j.1600-6143.2005.00961.x.

    Article  PubMed  Google Scholar 

  18. Schlansky B, Shachar C. Implications of expanded medicaid eligibility for patient outcomes after liver transplantation: caveat emptor. Liver Transplant. 2016;22:1062–1064. https://doi.org/10.1002/lt.24491.

    Article  Google Scholar 

  19. Tumin D, Foraker RE, Smith S, Tobias JD, Hayes D. Health insurance trajectories and long-term survival after heart transplantation. Circ Cardiovasc Qual Outcomes. 2016;9:576–584. https://doi.org/10.1161/circoutcomes.116.003067.

    Article  PubMed  Google Scholar 

  20. @KaiserFamFound. Status of state action on the medicaid expansion decision. http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/, 2017. Accessed 24 July 2017.

  21. Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006;6:783–790. https://doi.org/10.1111/j.1600-6143.2006.01242.x.

    Article  PubMed  CAS  Google Scholar 

  22. Beal EW, Black SM, Mumtaz K, et al. High center volume does not mitigate risk associated with using high donor risk organs in liver transplantation. Dig Dis Sci. 2017;62:2578–2585.

    Article  PubMed  Google Scholar 

  23. Graham JW, Olchowski AE, Gilreath TD. How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prev Sci. 2007;8:206–213. https://doi.org/10.1007/s11121-007-0070-9.

    Article  PubMed  Google Scholar 

  24. White IR, Royston P, Wood AM. Multiple imputation using chained equations: issues and guidance for practice. Stat Med. 2011;30:377–399. https://doi.org/10.1002/sim.4067.

    Article  PubMed  Google Scholar 

  25. Rosenbaum S. Medicaid payments and access to care. New Engl J Med. 2014;371:2345–2347. https://doi.org/10.1056/NEJMp1412488.

    Article  PubMed  CAS  Google Scholar 

  26. MACPAC. Examining access to care in medicaid and CHIP. https://www.macpac.gov/wp-content/uploads/2015/01/Examining_Access_to_Care_in_Medicaid_and_CHIP.pdf, 2011. Accessed 11 Aug 2017.

  27. Liao JM, Fischer MA. Restrictions of Hepatitis C treatment for substance-using medicaid patients: cost versus ethics. Am J Public Health. 2017;107:893–899. https://doi.org/10.2105/AJPH.2017.303748.

    Article  PubMed  Google Scholar 

  28. Barua S, Greenwald R, Grebely J, Dore GJ, Swan T, Taylor LE. Restrictions for medicaid reimbursement of sofosbuvir for the treatment of hepatitis C virus infection in the United States. Ann Intern Med. 2015;163:215–223. https://doi.org/10.7326/M15-0406.

    Article  PubMed  Google Scholar 

  29. Dumortier J, Boillot O, Scoazec JY. Natural history, treatment and prevention of hepatitis C recurrence after liver transplantation: past, present and future. World J Gastroenterol. 2014;20:11069–11079. https://doi.org/10.3748/wjg.v20.i32.11069.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Beal EW, Tumin D, Mumtaz K, et al. Factors contributing to employment patterns after liver transplantation. Clin Transplant. 2017;31:e12967. https://doi.org/10.1111/ctr.12967.

    Article  Google Scholar 

  31. Breathett K, Allen LA, Helmkamp L, et al. The Affordable Care Act medicaid expansion correlated with increased heart transplant listings in African-Americans but not Hispanics or Caucasians. JACC Heart Fail. 2017;5:136–147. https://doi.org/10.1016/j.jchf.2016.10.013.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Charles EJ, Johnston LE, Herbert MA, et al. Impact of medicaid expansion on cardiac surgery volume and outcomes. Ann Thorac Surg. 2017. https://doi.org/10.1016/j.athoracsur.2017.03.079.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Puls MW. 2015 ACS governors survey: surgeons describe the ACA’s effects on access to care. The Bulletin. http://bulletin.facs.org/2016/05/2015-acs-governors-survey-surgeons-describe-the-acas-effects-on-access-to-care/, 2016. Accessed 14 Aug 2017.

  34. Giladi AM, Aliu O, Chung KC. The effect of medicaid expansion in New York State on use of subspecialty surgical procedures by medicaid beneficiaries and the uninsured. J Am Coll Surg. 2014;218:889–897. https://doi.org/10.1016/j.jamcollsurg.2013.12.048.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Al-Refaie WB, Zheng C, Jindal M, et al. Did Pre-Affordable Care Act medicaid expansion increase access to surgical cancer care? J Am Coll Surg. 2017;224:662–669. https://doi.org/10.1016/j.jamcollsurg.2016.12.044.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216:482–492. https://doi.org/10.1016/j.jamcollsurg.2012.11.014.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Singh TP, Givertz MM, Semigran M, DeNofrio D, Costantino F, Gauvreau K. Socioeconomic position, ethnicity, and outcomes in heart transplant recipients. Am J Cardiol. 2010;105:1024–1029. https://doi.org/10.1016/j.amjcard.2009.11.015.

    Article  PubMed  Google Scholar 

  38. Martin M, Beekley A, Kjorstad R, Sebesta J. Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. Surg Obes Relat Dis. 2010;6:8–15. https://doi.org/10.1016/j.soard.2009.07.003.

    Article  PubMed  Google Scholar 

  39. Allen JG, Weiss ES, Arnaoutakis GJ, et al. Insurance and education predict long-term survival after orthotopic heart transplantation in the United States. J Heart Lung Transplant. 2012;31:52–60. https://doi.org/10.1016/j.healun.2011.07.019.

    Article  PubMed  Google Scholar 

  40. Bennett KM, Scarborough JE, Pappas TN, Kepler TB. Patient socioeconomic status is an independent predictor of operative mortality. Ann Surg. 2010;252:552–558. https://doi.org/10.1097/SLA.0b013e3181f2ac64.

    Article  PubMed  Google Scholar 

  41. Herring AA, Woolhandler S, Himmelstein DU. Insurance status of U.S. Organ Donors and Transplant Recipients: the uninsured give, but rarely receive. Int J Health Serv. 2008;38:641–652. https://doi.org/10.2190/HS.38.4.d.

    Article  PubMed  Google Scholar 

  42. @KaiserFamFound. Health insurance coverage of the total population. http://www.kff.org/other/state-indicator/total-population/, 2016. Accessed 15 Aug 2017.

Download references

Author information

Authors and Affiliations

  1. Division of General and Gastrointestinal Surgery, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Clifford Akateh & Eliza W. Beal

  2. Division of Transplantation, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Clifford Akateh, Eliza W. Beal & Sylvester M. Black

  3. Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Khalid Mumtaz

  4. Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Don Hayes Jr.

  5. Section of Pulmonary Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, 43205, USA

    Don Hayes Jr.

  6. Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, 43205, USA

    Dmitry Tumin & Joseph D. Tobias

  7. Department of Anesthesiology and Pain Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43205, USA

    Joseph D. Tobias

  8. Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, 43210, USA

    Dmitry Tumin & Don Hayes Jr.

  9. Ohio State University Wexner Medical Center - Faculty Tower, 395 W 12th Ave, Room 654, Columbus, OH, 43210-1267, USA

    Clifford Akateh

Authors
  1. Clifford Akateh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dmitry Tumin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eliza W. Beal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Khalid Mumtaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph D. Tobias
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Don Hayes Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sylvester M. Black
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Clifford Akateh.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Disclaimer The data reported in this manuscript were supplied by the United Network for Organ Sharing as the contractor for the Organ Procurement and Transplantation Network. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the OPTN or the U.S. Government.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Akateh, C., Tumin, D., Beal, E.W. et al. Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes. Dig Dis Sci 63, 1463–1472 (2018). https://doi.org/10.1007/s10620-018-5031-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-018-5031-6

Keywords

Search

Navigation